Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders for two residents. One resident with vertebral fractures, neuropathy, chronic low back and shoulder pain, and a recent right rotator cuff repair had care plan interventions that included administering medications as ordered. Physician orders in December included a daily topical lidocaine patch and Percocet 7.5-325 mg PO every six hours as needed for pain, with the Percocet order starting on 12/23/25 and ending on 12/29/25. The resident’s prescription from an orthopedic surgeon also specified Percocet 7.5-325 mg every six hours as needed with a 10-day supply. The MAR showed Percocet was administered daily from 12/24/25 to 12/29/25, and progress notes documented that the DON received an order from an NP on 12/29/25 to discontinue Percocet due to the resident’s drug-seeking history. However, the controlled substance administration record showed Percocet was administered at least daily from 12/24/25 through 12/30/25, and the DON verified the resident continued to receive Percocet on 12/30/25 without a physician order. The second resident, admitted with diagnoses including insomnia, epilepsy, schizophrenia, anxiety, and senile degeneration of the brain, was cognitively impaired and required staff assistance with hygiene, dressing, and transfers. Progress notes documented that this resident was sent to a hospital for evaluation after receiving an excessive dose of melatonin. The hospital ED note stated the resident was evaluated for drug overdose after being accidentally administered approximately 22 mg of melatonin at the facility, and that the MD, after consulting the poison center, noted melatonin was not expected to cause concern and the resident was asymptomatic. The resident returned to the facility the same day with no new orders. Review of physician orders for the relevant period showed no orders for melatonin, and the DON confirmed that a nurse had administered approximately seven melatonin 3 mg tablets to the resident. Facility policy on administering medications required that medications be given in accordance with orders, that staff initial the MAR after each medication, and that the individual administering medications verify the right resident, medication, dose, time, and route by checking the label three times before administration.
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